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Northeast Texas Community College Fire AcademyWaiver of LiabilityI, the undersigned, a private person, for and in consideration of the privilege of participating in any event sponsoredand sanctioned by Northeast Texas Community College, and in recognition that such participation involves certaininherent dangers, do hereby release Northeast Texas Community College, its administrators, agents, and employeesin both their public and private capacity from any and all liabilities, claims, suits, demands, or causes of action whichmay arise from my participation as aforementioned.This release shall be binding upon my successors and heirs.Signed:Sworn to and subscribed before me byonThis day of , .NoNotary Public in and for County, TexasMy commission expirestSeal:7

Northeast Texas Community CollegeFirefighter Medical Examination CertificationCandidate Full NameDate of Birth (mm/dd/yyyy)AddressCityStateZipIn consideration of being considered for acceptance into the Northeast Texas Community College FireAcademy, I authorize my physician to release this medical evaluation to the Northeast Texas CommunityCollege Fire Academy. I understand that this certification is not public information and that the academywill protect this privacy of this information.SignatureDatePhysician CertificationI certify that I have examined the fire academy trainee candidate listed above, including medical history,physical examination, and any tests deemed necessary {lab work, x-rays, EKG). I have also reviewed thelist of firefighter essential job tasks included with this form.l is my medical opinion that, as of the date of the examination, this candidate (mark one box)Can safely perform the job tasks listed.Cannot safely perform the job tasks listed.Physician Name (Print)AddressCityPhysician SignatureStateDate8Zip

Firefighter Essential Job TasksExcerpted from NFPA 1582Standard on Comprehensive Occupational Medical Program for Fire DepartmentsA firefighter trainee shall be medically and physically able to:1. While wearing personal protective equipment (PPE) and self-contained breathing apparatus{SCBA), perform firefighting tasks (operate and pull hose lines, crawl extensively, lift and carryheavy objects, use power and hand tools), perform rescue operations, and other emergencyresponse actions under stressful conditions, including working in extremely hot or coldenvironments for prolonged time periods.2Wear an SCBA, which includes a demand valve type positive pressure face piece, requiring the abilityto tolerate increased respiratory workloads.3Be exposed to smoke, heated gases, and possibly other contaminates in spite of wearingSCBA.4Climb four (4) flights of stairs while wearing PPE and SCBA weighing at least 50 pounds, whilealso carrying tools or equipment weighing up to 40 pounds additional.5Wear a fire protective ensemble, including SCBA that is encapsulating and insulated whichmay result in fluid loss and can elevate core body temperature.6While wearing PPE and SCBA, search for, locate, and drag victims of various weights up to200 pounds or more despite hazardous conditions and low visibility.7. While wearing PPE and SCBA, advanced water filled hose lines up to 2 W*in diameterfrom fire apparatus to building (150feet or more), which can involve negotiating flights ofstairs, ladders and other obstacles.8While wearing PPE and SCBA, climb ladders, operate from heights, walk, or crawl, in the darkalong narrow or uneven surfaces.9Perform critical, time sensitive complex problem solving during physical exertion instressful, hazardous environments, including hot, dark, and/or tightly enclosed spaces.10 Communicate (give and comprehend verbal orders) while wearing PPE and SCBA underconditions of high background noise, poor visibility, and wet conditions.11 Function as an integral member of a team, where sudden incapacitation of a teammember may put other team members at significant risk.9

Uniform RequirementsEach Fire Academy Trainee is required to have uniforms of the following components:ShirtBlue shirt (will be designed and printed by local print shop)PantsNavy work pant with standard pockets and cut (no tactical pants, or EMS trousers).BeltPlain black leather uniform belt, 13/8" to 1W' in width. Plain buckle.ShoesBlack leather, plain rounded toe, shoes or boots that can be polished. Shoes must bedress/uniform types shoes or boots. Athletic shoes or cowboy boots are not acceptable.Each trainee must have at least two (2) shirts with and two (2) pants. If you want to buy more, that is up toyou. Only one belt, and one pair of shoes/boots is required.Trainees should have a uniform appearance. Therefore, no substitution of brands, colors, or itemnumbers is allowed, other than as noted above. Uniforms are to be purchased by the trainee and mustbe worn on the first and all subsequent days of class, and t-shirt can be worn during hands-on sessions.Personal Protective EquipmentEach trainee is required to have a complete set of personal protective equipment (PPE)meeting the requirements of the Texas Commission on Fire Protection(TCFP) and NFPAStandard 1351, Standard on Selection, Care, and Maintenance of Protective Ensembles forStructural Fire Fighting and Proximity Fire Fighting. A complete set of PPE includes protective coatwith wristlets and collar; protective trousers with suspenders; bunker boots; helmet with faceshield, earflaps, and chin strap; protective hood; and gloves.If a trainee owns PPE or has PPE issued by a fire department, it may be used if it meets therequired standards. Otherwise, PPE rental is recommended. Trainees may use any vendor of theirchoice, and equipment must be certified and meet academy and TCFP and NFPA standards.Regardless of the source of the PPE, it must meet these requirements: PPE must be compliant with NFPA 1851 requirements on age of PPE. No PPE over 1)years old shall be used. PPE used must have received an Advanced Inspection verifying compliance withstandards in NFPA 1351 and TCFP regulations. Lf the PPE is issued by a departmentsubject to NTCCFP regulation, it probably meets this standard. PPE issued by volunteerdepartments and departments in other states may not. It is the responsibility of eachtrainee to ensure PPE meets standards! This inspection must be performed by personnelqualified to make these inspections under NFPA 1851standards and must bedocumented. If the PPE is issued by a department, the chief of the department mustcomplete and sign the PPE form provided in the Fire Academy Packet. PPE provided byFirst-In Fire Solutions and most other rental companies will have these certifications.PPE must be clean and in good repair. During the academy, PPE must be maintained in good repair and kept clean. If theAcademy Coordinator or Instructor determines that any trainee's PPE is damaged or dirty, thetrainee will not be allowed to participate in drills requiring PPE until the damaged/dirty PPE hasbeen cleaned, repaired, or replaced.Protective Clothing Certification FormThis attached form is required only if protective clothing is being provided by a firedepartment for a sponsored trainee. If this applies, the Fire Chief must complete the form. Alongwith the signed form, copies of the most recent advanced inspection and advanced cleaningrecords must be submitted. If you are renting protective clothing this form is not required. Therental agency will provide the required records to the academy.10

Northeast Texas Community College Fire AcademyProtective Clothing CertificationThe Fire Department listed below wishes to provide protective clothing to our member who is enrolled in theNortheast Texas Community College Fire Academy. As Fire Chief, I certify to the academy all of thefollowing:1. Protective clothing consists of bunker coat, bunker pants, boots, gloves, hood, and helmet with faceshield (or goggles) and ear protection. (A gear bag is optional but recommended).2. I certify that the protective clothing provided has not been modified in any way, except as approvedby the manufacturer and in accordance with NFPA 1851 and Texas Commission on FireProtection regulations.3. This protective clothing was purchased in accordance with NFPA standards and met therequirements of the edition of NFPA 1971, Standard on Protective Ensembles for Structural FireFighting and Proximity Fire Fighting that was in effect at the time of purchase.4. This protective clothing has been inspected, tested, cleaned, and maintained in accordancewith NFPA 1851, Standard on Selection, Care, and Maintenance d Protective Ensembles forStructural Fire Fighting and Proximity Fire Fighting, and applicable Texas Commission on FireProtection regulations.5. I certify that the most recent advanced inspection on the provided protective clothing was done ondate) and that the protective clothing met the standards in NFPA 1851or was repaired in accordancewith those standards.6. I certify that the most recent advanced cleaning of this protective clothing was done on(date) and that said cleaning was done in accordance with NFPA 1851 andapplicable Texas Commission on Fire Protection regulations.7. I certify that the protective clothing provided is in good condition, clean, and meets all applicablestandards for use. I understand that if protective clothing is damaged in the academy, or is foundupon inspection by academy staff to not be in compliance, it must be replaced or repaired before thetrainee is allowed to participate in any activities requiring protective clothing.Trainee NameAddressDepartment st Texas Community College is an equal opportunity, affirmative action, ADA institution.11

Random Drug ScreenI understand that I am required to undergo a randomdrug screen. I further understand that if I fail the drug screen(s), I may be dropped from theacademy unless proof of prior treatment and prescription from my health care provider isprovided to the satisfaction of the academy coordinator and the NTCC Continuing Educationdepartment. Violation of illegal substances will result in automatic dismissal from the academy.Student SignatureDate12

NORTHEAST TEXASCOMMUNITY COLLEGECONTINUING EDUCATION FINANCIAL AIDContinuing Education Financial Aid Policy and ProceduresFor Financial Aid AssistanceNortheast Texas Community College (NTCC) financial aid program for Continuing Education is designed to assist studentswhose family or personal circumstances make financial assistance necessary to meet tuition, fees, and/or books. The TexasPublic Educational Grant (TPEG} program is available for eligible students enrolling in eligible continuing educationprograms. For course information, call the Continuing Education Office at (903) 434-8134 or email continuinged@ntcc.edu1Funds are awarded based on the availability and the number of applicants applying. Funds may cover the cost oftuition, fees, or books.2.The Texas Public Educational Grant is awarded on the basis of financial need.3.NTCC adheres to the "federal financial need formula" to determine a student's financic1I need. Students mustcomplete the Free Application for Federal Funds at least '1 weeks prior to starting classes. Applications forFederal funds are available in the Financial Aid Office located in the Administration Building.4.An institutional application may be picked up in the Continuing Education Office. This will determine if thestudent needs to complete the FAFSA.5. Students are required to apply annually for the TPEG funds.6.Students may be required to submit other income documents.7.Students enrolling in continuing education courses are not required to enroll in credit courses.8.Continuing Education financial aid recipients may not be eligible for future assistance if students withdraw or do notsatisfactorily complete all course work.13

FINANCIAL AID APPLICATIONPart I Continuing Education Office Use OnlyEducational Skill UpgradeyesnoProgram Eligibility for Fundingyesno(if no, not eligible for financial aid)Satisfactory Progress Statusyesno(if no, not eligible for financial aid)Signature of CE StaffDate:Part II - Applicant - Complete All Information:Name Social Security NumberMailing Address:CityI am applying for the following quarters:Zip1st 2ndI am requesting financial aid for (check one):3thTuitionWhere will you be living during the academic term?PhoneFeesWith Parents4thBooksOff CampusIndicate all colleges, universities, trade, and/or technical schools previously attended:School NameCity/StateDate AttendedDid you receive financial aid?I certify that the information I have reported on this application is complete and correct.Student SignatureDate*** Submit this application with the Continuing Education registration form and the Student Aid Report to the14

Financial Aid DepartmentStatement of Student Eligibility2019-2020 School YearFirst NameHome PhoneLast NameSSN or Student ID NumberCell PhoneEmail AddressHave you ever been convicted of a felony or an offense under Chapter 481, Health and SafetyCode (Texas Controlled Substances Act), or under the law of another jurisdiction involving acontrolled substance as defined by Chapter 481, Health and Safety Code?YESNO*If your answer is yes, contact the financial aid office to determine your eligibility to receive a TEXASGrant, Texas Educational Opportunity Grant, or Texas Public Educational Grant.I hereby certify that the information I have provided in this statement is true and correct. I understandthat if I fail to provide accurate information, I may be required to reimburse the institution and penaltiesmay be imposed. I also understand that it is my responsibility to inform the financial aid office if mystatus changes at any time while attending this institution.15

Student SignatureDate16

Evidence of Vaccination against Bacterial MeningitisPurpose of Form: This form may be used by any incoming student to Northeast Texas Community College in order tosatisfy the requirement to submit evidence of a bacterial meningitis vaccination, in compliance with Texas Senate Bill1107. The complete form can be hand-delivered, mailed, faxed or emailed to the Registrar’s Office, Northeast TexasCommunity College, PO Box 1307, Mount Pleasant, TX 75456, Fax: 903-572-6712, Email: bgooding@ntcc.edu.This section should be completed by the studentStudent Last Name:Student First Name:Student ID or SS#:Date of Birth:/MonthPhone Number:/DayYearPreferred Email Address:First Semester at Northeast Texas Community College (Select one and indicate the appropriate year): Spring, Year: Summer, Year: Fall, Year:By signing this form, I certify that the information provided is true and accurate and I understand the rules and regulationsconcerning the bacterial meningitis vaccination requirement.Student Signature:Date/Month/DayYearThis section should be completed by a licensed Health Practitioner or Designee.Last/Family Name of the Health Practitioner who administered the vaccination:First/Given Name of the Health Practitioner who administered the vaccination:Date of the administration of the bacterial meningitis vaccination:/Month/DayYearLast/Family Name of the vaccination recipient (i.e. the student):First/Given Name of the vaccination recipient (i.e. the student):Date of birth of the vaccination recipient (i.e. the student)://MonthDayYearBy signing this form, I certify that the information provided is true and accurate. Specifically, I certify the following: I am a Health Practitioner authorized by law to administer an immunization or I have legal designation to complete andsign this form on behalf of a Health Practitioner authorized by law to administer an immunization. The individual who administered the bacterial meningitis vaccination to the student named above is or was a HealthPractitioner authorized by law to administer an immunization. The bacterial meningitis vaccination was administered to the student named above by the Health Practitioner namedabove and on the date provided above.Health Practitioner or Designee Signature:DateMonth17/Day/Year

License Number:Phone:18

Pleasant Fire Department is a career fire department serving the citizens of Mt Pleasant, Texas. The Northeast Texas Community College Fire Academy prepare trainees for a career as a firefighter. The academy is an authorized training facility for structural firefighting under Texas Commission on Fire Protection (TCFP - FDID #107).